Name: Dorothy Sawo
Doctoral Candidate Nursing Practice, Pace University, NYC
Name: Nancy Cherofsky
Doctoral Candidate Nursing Practice, Pace University, NYC
Centre conducting review
Pace University Leinhard School of Nursing in collaboration with the The New Jersey Center for Evidence Based Nursing: A Collaborating Centre of the Joanna Briggs Institute, University of Medicine and Dentistry of New Jersey School of Nursing, Newark, USA.
The objective of this systematic review is to determine the best available evidence related to the effectiveness of telehealth interventions on specific outcomes related to adult patients with congestive heart failure (CHF) in long term home health care.
Review Question: In adult patients with CHF in long term home health care what are the effects of telehealth interventions (telemonitoring and telephone support) versus usual care (care provided by a home health care nurse) on rates of rehospitalization, urgent care visits, emergency room (ER) visits and patient's perceived quality of life?
The specific review questions to be addressed are as follows:
- What is the effect of telehealth interventions (telemonitoring and telephone support) versus usual care in the management of adult patients with CHF in long term home health care on hospital readmission rates, urgent care visits rates, ER visits rates, and patient's perceived quality of life?
- What is the effect of follow-up telephone calls versus usual care in the management of adult patients with CHF in long term home health care on hospital readmissions rates, urgent care visits rates, ER visits, and patient's perceived quality of life?
- What is the comparative effectiveness of telehealth interventions, specifically telemonitoring and telephone support versus telephone follow-up calls in the management of adult patients with CHF in long term home health care on hospital readmission rates, urgent care visits rates, ER visits rates and patient's perceived quality of life?
Chronic conditions, including cardiovascular disease (CVD), diabetes, cancers and respiratory diseases, account for 59% of the 57 million deaths annually and 46% of the global burden of disease (WHO). 7 According to the WHO high blood pressure, tobacco use, high blood glucose, physical inactivity, overweight and obesity are responsible for raising the risk of chronic diseases such as heart disease and cancer. 7 The European Society of Cardiology (ESC) represents countries with a population of greater than 900 million. There are at least 15 million patients with heart failure (HF) in those 51 countries. 8 The prevalence of HF is between 2% and 3% and rises sharply at approximately 75 years of age, so the prevalence in 70 to 80 year-old people is between 10% and 20%. 8 The rate of CHF is as prevalent in European countries as it is in the United States.
Bodenheimer et al., 9 reported that in the United States the nation's 65 year-and-older population will swell from 35 million in 2000 to 53 million in 2020 as the baby-boomer generation reaches the age of increased chronic disease prevalence. The major chronic illnesses in the United States are hypertension, asthma, diabetes, congestive heart failure (CHF), renal failure, and depression. The challenge to the healthcare system is finding effective strategies for helping people with chronic illnesses manage their health care. Heart disease (which includes CHF) is the number one cause of death in men and women in the United States. 10 Approximately 5.8 million people in the United States have heart failure. About 670,000 people are diagnosed with it each year. 10
Heart disease is one of the prominent chronic illnesses identified by Healthy People 2010 as a priority for attention in the United States. Of the ten leading diagnoses of hospital discharges in 2006, cardiovascular disease ranked number one. 10 CHF results in marked disability, and a decrease in self-care and daily activity. 11 CHF is also the leading cause of hospitalization in people older than 65. Lee et al. 11 state that the driving force behind heart failure costs is hospitalization of the elderly. Fang et al., 12 conducted a review of heart failure-related hospitalizations in the United States from 1979 to 2004 and found that the number of hospitalizations with the mention of heart failure tripled from 1,274,000 in 1979 to 3,860,000 in 2004; 65% to 70% of admissions were patients with secondary diagnosis of heart failure. Hospital readmission rates for people with heart failure are comparatively high both at a international, national and organizational level. Readmission to acute care facilities is a frequent and costly problem among older adults with CHF. 14 Jencks et al 14 analyzed Medicare claims data from 2003-2004 to describe the patterns of rehospitalizations and the relationship of rehospitalization to demographic characteristics of patients and to characteristics of the hospitals. The result of the study showed that the rehospitalization rate in the Medicare fee-for-service program is almost one fifth (19.6%) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital and were rehospitalized within 30 days. In addition 34.0% of patient beneficiaries were rehospitalized within 90 days, and 67.1% of patients who had been discharged with a medical condition and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. The rate of hospitalizations and rehospitalizations carries an enormous cost, both in human and financial capital. Stewart et al 15 reported that in the United Kingdom heart failure is the cause of 5% of acute hospital admissions, is present in 10% of patients in hospital beds, and accounts for approximately 2% of national expenditure on health care due to the cost of hospital admissions.
Over the years, a number of studies have been conducted investigating outcomes of interventions directed toward symptomatic relief of CHF and improving quality of life with the use of telehealth technology. Telehealth technologies are rapidly advancing and have evolved from the use of narrow-band transmission modalities (i.e., telephone) to various broadband transmission modalities (i.e., cable, digital subscriber lines, and wire-less satellite).16
Moore 17 stated that the most significant contribution of telehealth to health system reform will be achieved if telehealth-supported team care is focused on the highest-complexity and highest-risk segments of the chronic disease populations for which it can yield the largest, near-term improvements in clinical, health status, and financial outcomes. Knox and Mischke 18 demonstrated that the concomitant use of telemonitors with home visits by clinicians, reduced length of stay (LOS), rehospitalization, and emergency room (ER) visits for congestive heart failure exacerbation. Lehmann et al., 19 in a randomized trial of 20 homebound CHF patients demonstrated that patients managing their CHF via telehealth technology decreased their overall utilization of healthcare resources by 41% (p=0.00183). In addition physician office visits decreased by 43% (p=0.000253), ER visits decreased by 33% (p=0.3770), and hospitalizations decreased by 29% (p=0.3872).
Dansky et al., 20 conducted a prospective randomized field experiment with a treatment group and equivalent group in 10 home health agencies on the impact of telehealth on clinical outcomes in patients with heart failure and found that on average patients in the telehomecare groups had a lower probability of hospitalization and emergency room (ER) visits than did patients in the control group. Louis et al., 21 conducted a systematic review of telemonitoring for the management of heart failure of eighteen observational studies and six randomized controlled trials and found that the observational studies suggested that telemonitoring used either alone or as part of a multidisciplinary care program, reduced hospital bed-days occupancy. The randomized controlled trials suggested that telemonitoring of vital signs and symptoms facilitated early detection of deterioration and reduced readmission rates and length of hospital stay in patients with heart failure. One RCT study in the review showed no difference in outcomes between the telemonitoring group and the standard of care group.
Another systematic review of telemonitoring for patients with chronic heart failure by Chaudhry et al 22 assessing the following interventions: telephone-based symptoms management, automatic monitoring of signs and symptoms and automated physiologic monitoring, found that six studies suggested reduction in all cause and heart failure hospitalizations (14% to 55% and 29% to 43%, respectively). A systematic review and meta-analysis of articles published between 1998 to 2008 on home telemonitoring for adult and pediatric patients with CHF by Polisena et al., 23 found seventeen studies that compared telemonitoring with usual care, four of which were RCTs, and three comparative arms: home telemonitoring, telephone support and usual. The result of the review only focused on the home telemonitoring and usual care component arms of the study. The overall findings were that home telemonitoring reduced mortality (risk ratio = 0.64; 95% Cl: 0.48-0.85) compared with usual care, and several suggested that home telemonitoring also helped to lower the number of hospitalizations and the use of other health services. Clark et al., 24 conducted a systematic review and meta-analysis of published randomized controlled trials comparing remote monitoring programmes with usual care in patients with chronic heart failure managed within the community to determine whether remote monitoring (structured telephone support or telemonitoring) without regular clinic or home visits improves outcomes for patients with chronic heart failure. This review found that of the 14 randomized controlled trials (4264 patients) that met the inclusion criteria, four evaluated telemonitoring, nine evaluated structured telephone support, and one evaluated both. The review also found that remote monitoring programs reduced the rates of hospital admission for chronic heart failure by 21% (95% confidence interval 11% to 31%) and all cause mortality by 20% (8% to 31%). Of the six trials evaluating health related quality of life, three reported significant benefits with remote monitoring, and of the four studies examining healthcare costs with structured telephone support, three reduced costs and one had no effect on quality of life measures. The authors concluded that programs for patients with CHF that include remote monitoring have a positive effect on clinical outcomes in community dwelling patients with chronic heart failure.
To the reviewers knowledge, analysis of systematic reviews of the role of telehealth in the management of CHF have focused on two interventions comparing telephone follow up vs. usual care, or telehealth vs. telephone follow up. This review will compare the effectiveness of telehealth interventions versus telephone support versus usual care on rates of rehospitalization, urgent care visits, emergency room visits and patient's perceived quality of life.
Definitions of Terms used in the systematic review
Congestive Heart Failure: Congestive heart failure (CHF) is an imbalance in pump function in which the heart fails to adequately maintain the circulation of blood. The most severe manifestation of CHF, pulmonary edema, develops when this imbalance causes an increase in lung fluid secondary to leakage from pulmonary capillaries into the interstitium and alveoli of the lung. 1
Long Term Home Health Care: Incl udes medical and non-medical care to people who have a chronic illness or disability. Long-term care helps meet health or personal needs. Long-term home health care is care provided for patients in their home, within their community. 2
Telehealth: Telehealth is the remote care delivery or monitoring between a healthcare provider and a patient. There are two types of telehealth: phone monitoring (scheduled encounters via the telephone) and telemonitoring (collection and transmission of objective and subjective clinical data through electronic information processing technologies). 3
Telemonitoring: Telemonitoring requires the use of technology and equipment and includes the collection of objective and subjective clinical data and the transmission of such data between a patient at a distant location and a health care provider through electronic information processing technologies. 3
Telephone Support Monitoring: Telephone monitoring is the scheduled remote care delivery or monitoring in which scheduled patient encounters via the telephone occur between a health care provider and a patient or caregiver. 3
Usual Care: Usual care is the care provided by the home health care nurse in monitoring the patients’ condition with CHF and includes the monitoring of blood pressure, heart rate, respiratory rate and auscultation of lung sounds, pedal edema, and medication management and compliance. Usual care also includes self-management support and care coordination with other providers and caregivers.
Rehospitalizations: Patient readmitted to a hospital after discharge for CHF. Rehospitalizations are any admissions related to CHF to a hospital after a discharge for CHF within a six-month period.
Urgent Care Visits: Defined as unplanned visits of an urgent nature to a hospital or independent urgent care center or physician for treatment of CHF. Patients are treated and released within 24 hours.
Emergency Room Visits: Defined as emergency visits to a hospital ER for treatment of CHF. Patients are treated and released within 24 hours or admitted to the hospital.
Patient's Perceived Quality of Life: Defined as a patient's personal view on how their daily life is and the quality of their life. Quality of life is considered the broadest conception, encompassing all factors related directly and indirectly to health status. The primary modern proponent of the broader view of health within the concept of quality of life has been the World Health Organization (WHO). In its Constitution of 1948, WHO defined health as “a state of complete physical, mental and social well-being, and not merely the absence of disease and infirmity.” 4, 5 Central to the concept of quality of life and its measurement is that the assessment should include not only the actual event or function per se but also the patient's perceptions of its impact on his or her life.” 6
Since treatments of congestive heart failure influence the quality of life of a patient, CHF specific questionnaires have been used in clinical trials. Health status questionnaires, whether more general or related to a specific medical condition, have been shown to be of value and to produce consistent results. A commonly used disease specific questionnaire for CHF is the Minnesota Living with Heart Failure Questionnaire (MLHFQ. The Minnesota Living with Heart Failure Questionnaire was designed specifically to measure a patient's perception of heart failure and its effects on daily life; the validity of the use of MLHFQ in drug trials and in comparison with placebo has been confirmed. 5
Prior to the initiation of this systematic review the Cochrane Library and its database of abstracts and systematic reviews were reviewed and the Joanna Briggs Institute (JBI) database were searched and no prior systematic reviews on this specific topic were identified.
Types of Participants
The review will consider all studies that include the following:
- Adult patients over the age of 18 years with a diagnosis of CHF in any classification (New York Heart Association (NYHA) Classes I-IV) receiving long term care from of a home health care agency.
Types of Interventions
Types of interventions of interest to perform this review will include:
- Telemonitoring and telephone follow-up calls (which fall under the umbrella of telehealth)
- The comparator is usual care
Types of Outcomes
Outcome measures for this review will include:
- Rehospitalization rates
- Urgent care visit rates
- Emergency room visit rates
- Patients’ perceived quality of life
Types of Studies
The review will include randomized controlled trials. In the absence of randomized controlled trials, quasi-experimental design studies will be considered for inclusion.
The search strategy utilized for the review will concentrate on finding published and unpublished studies and papers in English language. The search strategy will be limited from 1995 to 2010.
The concept of telehealth and telemedicine dates back as far as the 1900's. The telephone was used as the main stay of medical communication then and continues to be utilized as a mainstay of telehealth delivery. 25 The objective of telehealth prior to 1995 was to assist in the diagnosis and delivery of health care services to patients in remote locations. The present concept of telehealth and telemedicine in the monitoring of patients with CHF became more prevalent in the mid 1990s with the rapid development of the Internet and electronic monitoring devices. During the 1990s the demand of developing countries around the world to contain escalating health costs for chronic diseases and deliver health care outside a hospital system, drove the demand of telehealth interventions in diseases such as CHF. 25 For these reasons the reviewers will limit the search strategy from 1995 to the 2010.
A four-step search strategy approach will be exercised in this review. An initial search of Medline and CINAHL will be undertaken with the keywords identified for this review. The Medline and CINAHL databases will be cross-referenced to avoid duplicate articles. A second search with the identified keywords and keywords newly identified in the initial search strategy will be undertaken. The third step will include close examination of the reference lists of all identified articles that can then be searched for additional articles. The fourth and final step will include contacting the authors of articles for verification of information pertaining to the author's articles if deemed necessary for this review.
The databases to be searched include:
- GOOGLE SCHOLAR
- Cochrane Central Register of Controlled Trials (CENTRAL)
The grey literature search included:
- New York Academy of Medicine
The reviewers acknowledge that each electronic database has its own indexing terms and attention will be given to uncover all terms relevant to the search. The reviewers will work with an experienced librarian to assist in the search of the databases and a hand search will be done to uncover any articles not indexed into the databases. Experts will be contacted to seek or clarify information pertaining to this review.
All articles and abstracts identified in this review will be independently reviewed by two reviewers. The reviewers will review the inclusion criteria on all articles and abstracts retrieved. The decision to include selected studies will be undertaken by two reviewers. If the two reviewers cannot agree, a third, or if necessary a fourth reviewer will be utilized and a decision will be made. The references for the review will be entered into the software package Endnote.
Assessment of Methodological Quality
Methodological quality for this review will be assessed using the critical appraisal instrument developed by the Joanna Briggs Institute (Appendix I).
Data collection for this review will be extracted using the standardized data extraction tool developed by the Joanna Briggs Institute (Appendix II).
The data will be synthesized and collected according to the following information:
- When possible odds ratio (for categorical outcomes data) or standardized mean differences (for continuous data) and their 95% confidence interval will be calculated for each included study.
- Heterogeneity of studies will be tested using standard chi-square test.
- If appropriate, with available data, results from comparable groups of studies will be pooled in meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI MASTARI). 26
- If statistical pooling is not possible the findings will be presented in narrative form.
Conflicts of Interest
The reviewers have no potential conflicts of interest in performing this review.
The reviewers would like to thank Dr. Cheryl Holly and her colleagues from UMDNJ (a collaborating centre for the Joanna Briggs Institute) for the training provided to perform this review. The reviewers would also like to thank Sonia Hines from the Joanna Briggs Institute who took the time to travel to our university to assist in questions for performing this review. The reviewers would also like to thank our clinical mentor, Ms. MaryJo Vetter, for her direction and interest in the subject material for the review. The reviewers would like to thank the Pace University Leinhard School of Nursing and the nursing professors of the DNP program for collaborating with the Joanna Briggs Institute. Last but not least, the reviewers would like to thank their academic advisor, Dr. Rona Levin for her continued and unrelenting assistance and guidance to carry out this review.
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JBI Critical Appraisal Checklist for Experimental Studies
JBI Data Extraction Form for Experimental/Observational Studies